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Swollen Scrotum- Orchitis

Orchitis or infection of the testicles is not a rare disorder and infact is frequently seen in young males. The most common cause of orchitis in North America is a virus infection. The virus that causes mumps has a great affinity for the testes and may affect either one of both testicles. About one-third of males who contract mumps after puberty develop orchitis. The disorder has been recognized since the time of Hippocrates. While the more common epididymo-orchitis is bacterial in origin, isolated orchitis usually has a viral etiology. Approximately 20% of prepubertal males with mumps develop orchitis. This viral disorder rarely occurs in post pubertal males with mumps. Bacterial orchitis is even rarer and is usually associated with a concurrent epididymitis in the older males. In the old days, it was thought that every time the testes got infected, sterility resulted. This is false and infertility as a result of mumps is quite rare. For those lucky to live in countries where the mumps vaccine is available, mumps orchitis is rare, but in those countries without the vaccine, mumps orchitis is quite high. Asides from virus, orchitis can also be acquired from bacteria and in North America this is being increasingly recognized in the sexually transmitted disease (STD) clinics. The majority of bacteria are the ones which cause sexually transmitted disease. So the best way to avoid orchitis is to avoid sexual behavior that can cause STDs.

Causes

The most common cause of orchitis is virus and bacteria. Orchitis usually occurs in individuals who: - have not been vaccinated against mumps - Being younger than 12 or older than 45 - Developing recurrent urinary tract infections - Recent surgery of the urinary tract - Recent surgery of the genitals - Congenital malformations of the urinary tract

Viral orchitis

Viral orchitis is almost always due to the mumps virus. It is known that pre pubertal males who contract mumps; at least 1/3 of them will develop orchitis during the course of the mumps infection. The testes usually get infected about 4-6 days after the mumps infection. The mumps virus has a tendency to spread to other parts of the body and loves to go to the testes. The typical features of a mumps virus induced orchitis include: - concurrent throat infection - swelling of scrotum soon after the throat infection - swelling of one side of the scrotum (70% of cases) - both testes affected (30% of cases) Besides the mumps virus, numerous other viruses can also cause orchitis. Rarely, mumps orchitis can occur after vaccination with the mumps, measles and rubella vaccine.

Bacterial orchitis

Bacterial orchitis is most common in the older males who are sexually active. Often the cause of the infection is an STD, particularly gonorrhea or Chlamydia The initial infection is always at the epididymis and then affects the testes. Bacterial infections also affect males who develop benign prostate hypertrophy. The features of a bacterial orchitis are: - gradual pain and tenderness in the scrotum - low grade fever - swelling of the scrotum - swelling of one side of the scrotum (90% of cases) The highest incidence of sexually transmitted epididymo-orchitis occurs in men ages 18- 35. High-risk sexual behaviors that can cause STDs also places one at developing sexually transmitted orchitis. The risk of orchitis is increased by having: - Multiple sexual partners - Sex with a partner(s) with STD - Unprotected sex - Recent history of STD In the older individuals, the cause of orchitis may not be related to sex but to anatomical abnormalities of the urinary tract. In these cases, surgery of the scrotum, insertion of catheters in the penis or medical instrumentation of the genital tract, may be associated with infection. In some individuals who are Immunocompromised (AIDs, chemotherapy), numerous other bacteria may also be responsible for orchitis.

Symptoms

Orchitis usually presents acutely and within 24-48 hrs, one will definitely know that something is not right with the testes. The features of orchitis include: - swollen testes (one or both) - moderate to severe pain in the groin - reddening of the scrotum and surrounding skin - tenderness to touch - Nausea and vomiting - General malaise - Low grade fever - Penile discharge - Enlargement of the prostate - Tenderness of the prostate - Painful rectal exam

Complications

When orchitis is not treated in a timely fashion several complications may occur. These include: - unilateral smaller testes - possible sterility if both testes involved - may have a high chance of developing testicular tumor - recurrent attacks

When to seek medical advice

If one develops sudden onset of pain in the scrotum or groin, a visit to the doctor is a must. There are other conditions which can also mimic orchitis and they include: - testicular torsion - inguinal hernia - Epididymitis.

Diagnosis

The diagnosis of orchitis may be apparent on a physical exam. One may have enlarged lymph nodes in the groin and a tender testicle or testicles. The rectal exam may reveal a tender prostate. Some men may have penile discharge. Blood and urine will be analyzed for the presence of bacteria. When viral orchitis is suspected, there are no laboratory tests required. The history and presentation is adequate in most cases. However, if a bacterial cause of orchitis is suspected, then the urine and any penis discharge are cultured. In young males, the tests should screen for all organisms that cause STD.

Imaging Studies

The most important condition to differentiate from orchitis is testicular torsion. A simple ultrasound test of the scrotum will help differentiate between the two. Missing a diagnosis of testicular torsion is not good for the patient and “hell” for the physician. This test can reveal the presence of a twisted spermatic cord and determine the cause of orchitis. In some cases, the Doppler ultrasound is inconclusive and a nuclear study is required. This test will confirm the presence or absence of testicular torsion which is more serious and carries grave consequences for the patient, if missed.

Treatment

The first treatment of orchitis is supportive and includes - Bed rest - Ice packs to relieve the swelling and pain - Scrotal support with the use of panties - Avoid any exercise or intercourse. There is no specific treatment for viral orchitis. The treatment is aimed at relieving the pain and swelling. One may take over the counter pain medications, have plenty of bed rest, wear scrotal support and apply cold packs. Most cases of mumps orchitis resolve spontaneously in 3-10 days. All bacterial causes of orchitis require antibiotic treatment. If the cause is an infection acquired during sex, the partner will also need treatment. And there are legal implications about informing a partner. The Government does not take it very kind when someone is out there spreading STDs. So do let your partner know. There are numerous drugs available which can easily treat most cases of bacterial orchitis. The class of antibiotics used to treat orchitis includes: - Cephalosporins (Ceftin) - tetracyclines (doxycycline) - macrolides (Zithromax) - sulphonomides (Bactrim) - fluoroquinolones (ciprol) One should take the entire course of antibiotics as recommended by your doctor. With appropriate antibiotic coverage, most cases of bacterial orchitis resolve without complication. All individuals treated for a sexually transmitted disease should be referred to their private physician or local health department for HIV testing.

Surgery

In rare instances, the treatment of orchitis is delayed and pus formation may occur. In such cases, a small surgical procedure may be required to remove the fluid or the pus from the scrotum. If the testis is destroyed, it may require complete removal. Unfortunately there is no cure for orchitis but the condition can be prevented. To protect against the mumps virus, one should get vaccinated. For the bacterial variety of orchitis use of condoms and limiting promiscuous behavior are the key.